Unasked, Unanswered

“Hi! I’m Reni, the medical student here today,” I say to the cargo pant-clad teenager sitting hunched on the exam table. “My pronouns are she/her. What are your name and pronouns?”

My smooth delivery is only somewhat ruined by my almost falling off the stool as I try to sit down hands-free. I look up once I’m less precariously perched, awaiting a reply.

“Oh, I’m Sam,” they shrug. “And any are fine.”

I glance at the electronic medical record’s dropdown menu of pronoun options. “He/him,” “she/her,” “they/them,” and “fill-in-the-blank” blink back.

I look back at Sam, trying to arrange my expression into a mixture of friendly curiosity and acceptance—an effort helped by years of training my eyes to emote over masks.

“Sounds good,” I respond slowly. “Do you have a preference as to which pronouns I use in today’s note?”

A blank stare. Shoulders tensed. A fidget with the zip of a hoodie. Legs uncrossed and recrossed. Their presence in the room palpably shrinks in on itself.

“He/him…I guess.”

Before I ask my next question, a wave of apprehension surges. Earlier in medical school, I would have immediately blurted out the question or skipped it entirely, hoping to avoid getting caught in the undertow of an awkward moment.

As someone who finds herself at home under the LGBTQIA2S+* umbrella, I always wonder if other LGBTQIA2S+ patients can sense the invisible bonds connecting us, or if they remain perceptible only to me.

I fiddle with my rainbow lanyard, hoping it’s enough of a subtle solidarity signal. I let the wave of anxiety roll over me and break.

“Sounds good. One more question before I dive into the reason you’re here today. Do you have a gender-identity label you prefer?” I brace for any further sign of defensive curling up like the pill bugs that run from sunlight (and my fingers) when I’m weeding.

“Um… uh… transfemme…something?” he muses. “Sorry, nobody’s ever asked me that before.”

My gaze skips back to his chart. Pediatrics, psychiatry, pediatrics, psychiatry… repeated over and over throughout his visit history, from childhood on.

Nobody has ever asked you that? My heart clenches.

No doctor has ever asked me about my own gender identity or sexual orientation, either. If they had, I might have told them that my sexual orientation falls under the “A, for asexuality” umbrella—a label typically used to self-describe someone who generally does not experience sexual attraction.

As with all of life, sexual attraction is a multidirectional spectrum, not a binary. It is also something that I’ve thought about one way or another almost every day since I was twelve, before I ever came across the term “ace” in my angsty teenage Tumblr scrolling.

Thoughts about sexuality remain a ghostly specter in the back of my mind, and not just because I care deeply about LGBTQIA2S+ health. They haunt me because sexuality is an integral part of every human being’s life and lived experience, deeply embedded in our cultural zeitgeist and affecting individuals regardless of their relationships, sexual orientation, sexual activity, age, ethnicity or any other characteristic.

You do not have to be sexually active to think about, and have, sexuality. You do not have to want to have sex to think about, and have, sexuality. Yet, both as a patient and as a student, I can count on one hand the number of times I’ve seen a physician ask about any aspect of sexuality.

More broadly, no doctor has ever asked me if I had any concerns or questions related to these topics. If anyone had, my teenage self might have told them that I felt confused about the lack of any urge to rip my crushes’ clothes off. For years, a vice of anxiety clamped around my chest whenever my friends talked about their seemingly unquenchable desire to get up close and personal with other people’s genitals, or when I got absorbed in a book where the characters couldn’t keep their hands off each other.

Is it really that hard to control themselves? I found myself wondering.

I thought for sure that something in me was broken. How could I not think that, when so much of U.S. culture is built on compulsory sexuality?

Even as an adult, I’ve found it hard to unlearn the years of cultural messaging that cemented my feelings of inadequacy around sexual desire and attraction into place. It has taken more than a decade of self-directed reading and learning about sexuality to get to a place that’s edging closer to self-acceptance. I still struggle with not wanting to change parts of myself, as I imagine most of us do, but I at least no longer feel that it’s me who is the problem.

Thinking back to my sixteen-year-old self, I’m determined to make this patient’s visit feel like a blank page that he can choose how to fill in.

“Thanks for sharing that, Sam. Now, what do you want to talk about today?”

Throwing out my mental template is difficult after the many hours spent hammering it in place through standardized patients and observed patient interactions. Instead of going through the checklist of medical history, surgical history, medications, allergies, family history and social history, I let him guide the conversation.

“Well, I made this appointment to talk about starting estrogen,” he muses, “but I don’t really know where to start.”

“Why don’t you tell me a bit about you? Whatever you think is important or that you would want your doctor to know about.”

His face brightens. He recommends a new video game. He shares some of his recent struggles with anxiety and goals for therapy. The rest of the visit slides by smoothly.

Going forward, I have made a point of asking every patient—regardless if they’re there for hormone therapy or depression or an annual return visit—what questions or concerns they have related to sex, gender and sexual health. This has led to a range of conversations—from clarifying the difference between orgasm and ejaculation to a revelation that a patient’s true reason for wanting to stop his SSRI antidepressant was that the drug made it difficult for him to achieve erection.

Most of the time, asking the question results in nothing. But the times when it does lead to something make it worth those extra seconds. They make me hopeful that one less patient will leave the clinic still carrying the buried fear and uncertainty that I, and so many others, have been afraid to voice.

As my patient stands at the end of the visit, I smile at the relaxed set of his shoulders and the upward turn to his mouth. I hope that, if nothing else, he has felt heard. If the questions we ask ever matter, I believe, it is for this—the spaces we can build for our patients before they’re forced to create room for themselves.

Because many of them won’t.

________

*LGBTQIA2S+ stands for lesbian, gay, bisexual, transgender and trans, queer and questioning, intersex, asexual or agender, and two-spirit. The plus sign (+) represents other identity terms that are not listed.  Two-spirit is an umbrella term that describes Indigenous people who have a gender identity that is a combination of masculine and feminine traits.